122 Stony Brook Trail Lot 32.t.l�vt•:�a a>�aFr":r't�EsFto 1'+a(gay ♦'r"-t� �',rr �f ij tt'^1a'C�•� 5� rY'; xi ,�� it +t• 't;•
AUTHORIZATION NO: , 14 4 DAVIE COUNTY HEALTH DEPARTMENT t/k o,.
-` o Environmental Health Section PROPERTY INFORMATION
Permitte,6 s. ` P.O.Box 848
Name bf�1r� Mocksville NC 27028' : Subdivision Name: NO'toaOrK. .
Phone 704-634-8760
Directions to property <� t�i.. �VUL Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#J`�2o- —z _ Z U
-' SYSTEM CONSTRUCTION
CsrJVNrJE+l 't.<< r`Rr` Road Name:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits:This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
` E1 ROl HEALTH°SPECLALJ T. DA ISSUED
i*'y'«>'""•,{'Rvfk iYr ta.'A'x�( 1 s`=. `�.w•�r H'.;s. _�-.,,,, =yti j '. .+,6 r i y'r'; .!'''.tom .l-,: -' .. �•�„� t '.h
.ry. 143 �¢ x ' a.
arc. DAVIE COUNTY HEALTH DEPARTMENT
} � � �' ✓.
IMPROVEMENT AND`OPERATION PERMITS PROPERTY INFORMATION
Fefi*f#ee s
Subdivision Name: 0km flp- 3i
.Direclionsto'property:' r.Gt' �.I 1 c �; Section:” Lot: .v.
IMPROVEMENT
PERMTTiL?_
1 � Tax Office PIN:#
i f 1 t�r t�►Jt;4r p..v �R1 [_ Road Name: , �� p
**NOTE**This Improvement Permit DOES NOT authorize the"'dnstruction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constiuction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater.Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
t t ,a ,�" - r�• i`i+� PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
t--ENVlkONMENTALt— H$PEC�I' St DA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
t. INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE S#BEDROOMS #BATHS:6 #OCCUPANTS GARBAGE DISPOSA .1��a or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT {/ #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE 2•�A""`4- PE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) L� NEW SITE R,ZREPAIR SITE
460
SYSTEM SPECIFICATIONS: TANK StzE .�C GAL. PUMP TANK 'GAL. TRENCH WIDTH ROCK DEPTH 1� LINEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: 4LL 00 C k-1\)TQUK
IMPROVEMENT PERMIT LAYOUT
�`
L ) p C7
f a n
"CONTACT A REPRESENTATIVE OF THE D IE CO Y HEALTH EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00- :30 P. .ON THE D INSTALLATION.TELEPHONE#IS(704)634-8760.. ,
OPERATION PERMIT (7 ads M T
r, 1EDBY:
o640A
hAol
lyo 4L
RL
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: `� Y
*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE.THAT M DESCRIBE A VE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL STEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF.TIME.
DCHD 05/96(Revised)
' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI 15,
r� Davie County Health Department
t� Environmental Health Section
f �V P.O.Box 848 MAY 2 2 M8
Mocksville,NC 27028
(704)634-8760 E11V1RotJME11TAL HEALTI!
DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
ALL THE REQUIRED INFORMATION IS PROVIDED. -
1. Name to be Billed Contact Person
Mailing Address l �' /s � �` Home Phone X'/- a
City/State/Zip L�iYJi�Ai✓J A�� o?�D/o2 Business Phone 3.36" 7,11 -o?ei�
2. Name on Permit/ATC if Different than Above / r
Mailing Address City/State/Zip
3. Application For: 0- Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: ®' House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
a'Dishwasher ZI-Garbage Disposal U Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: C Iiitylcity ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ��"4WRITE
DIRECTIONS(from
Tax Office PIN: # 2,p -
- 1 Mocksville)TO PROPERTY-
/V
ROPERTY:
Property Address: Road Name /I, 1 t�
I I 1 1 N /v.
city/Zip n , A). C 1
1 e d N
1
If in Subdivision provide information,as follows: 1
Name:
1
1
Section: Lot #: �� 1
1
1
This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter
are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is
falsified or changed.I,also,understand that I am responsible for all charges incurred from this application.I,hereby,give consent to
the Authorized Representative of the DavieCountyHealth Department to enter upon above described property located in Davie County
and owned by Z�t? e�P NNe44 E-k AL to conduct all testing procedures
as necessary to determine the site suitability.
DATE S/o7�2`/a SIGNATURE �
Revised DCHD(06-96)
N 74.11'54' E 55.04 " C
���• N 31.87 S 426$3 E / PROPE IN \ s 86.08137' E
NO !CALF �, N 32.33'01' E N 33.16•53. C 110.89
VICINITY MAP P 29.45 • 46.84
N 378,49, E n 131 z�E. 1p y � J
N 53'35'59'' E pap-miT� 1132- >o.
6Gj 110.00.. . / t 1(9'7 } r?r9.v�cr�Jr��9. °� F 9•�
N 60.29'02' E F
G� 1$ 71.52
���• �� N 32.04'06' E � \ \ °• \ o� p ,7
p� 63.11 \ \ o �,� LOT
18
%�c (1,279 AC.) o gti��w
N SW
110.319, E \ 0`- �. `�� �Cr �• = LOT � 51brj?.
C2.2a.+
N 58.1 309 E
100.00
Ir. LOT #17 318
9� \ \ ? `\ \F •�, \ (0.94X.) CIO-
,
LOT #20
(2.913 AC.)
a _
9
LOT16\ \\\'oti
ma/ u
\ B 27' E A36.94
LOT4c.� LOT 65 \ \\ ��` '09so1' e " eg�3o 171.94
LOT #32 125. /
(2.329 AC.)
r40
\ ✓ �,
ti s ``, � /`g y� / LOT #21 ,ti`'�, •: '"o.
r��� •s • ��� sr• r° \ � �� L / (0.694 AC.) cb q ti a LOT #23 =
. c �^ ,�� sF�' \\\\ / ti ti LOT #22 r (0.860 AC.)
Aod, Nc'Qc�yF,ogC'� �' � �'�\\ � (0.750 AC.) LOT .#24
SS ��A`�s ``,ry- LOT #13 z o� g�� t N r (1.225 AC.)
�SF �`S \ (0.753 AC.) .ya s416O•A6+OA
• to d
d 23
� P�' • S FNT,yssf� ,�"o�ko°�Q" � /i (9hf'ofa°\�.' � � \\ o� c�9 z
•� \ `� \9�\\ /g k� at,9sh `�e cJ A CIS- — C16� j9
pie t-�ri^ ;
cou
LOT #30
RT��`' '� Q°�• '' � � (0.698 AC.) m cz,_ 2 i LOT #2
�J 0• 1�' ? (00747 c.? ��� j / 0'a SLOT #29 ,o•c'm —C21— (1.104 AC`,
EASEMENT C
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT 32--
Soil/Site Evaluation
APPLICANT'S NAMEgood DATE EVALUATED
PROPOSED FACILITY NayS� PROPERTY-SIZE Z 4CM>
SUBDIVISION �BI'L'31�+7r�01� ROAD NAME i '`d�G -C�iQ I(,
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 1,
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH -
Texture group G
Consistence
Structure SMIL
Mineralogy
HORIZON III DEPTH 21,E -
Texture group
Consistence SS
Structure
Mineralogy ;
HORIZON IV DEPTH p k
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATEZ.) (�. n
SITE CLASSIFICATION: 1 S EVALUATION BY: �A4•{ -!/mo'`'t/
m i
LONG-TERM ACCEPTANCE RATE: D• OTHER(S)PRESENT:
REMARKS: �jQ�tal w�� rdYt��� S�S'`�y+�_ 'OIy AOL 5100 rnr— (-n-f
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable . FR-Friable FI-Firm VFI-Very firm EFI Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-tern acceptance rate-gal/day/ft2
DCHD(01-90)
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` Davie County Heafth Department
3P99a and.dome Health Agency
FaC,N o2� Environmenta(Health Section
(�v 1$�6 P.O.Box 848/ 210 HOSPITAL STREET
COURIER#09-40-06
MOCKswLLE,N.C.27028
PHONE:(704)634-8760
June 5, 1998
Harry J. Brown, Jr.
6885 Idols Rd. , Apt. A
Clemmons, NC 27012
Re: Site Evaluation
Northbrook I/Lot 32
Stony Brook Trail
Tax PIN: 45820-32-2220
Dear Client(s) :
As requested, a representative from this office visited the
aforementioned site on June 3, 1998. Based upon the information
provided on the application for site evaluation and after the evaluation
was completed, the site was found to be provisionally suitable for installation
of an on-site sewage disposal system.
Before a permit can be issued the appropriate application must be filled
out and the house/mobile home location>staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
Jef uc amp,
Environmental Health Specialist
JB/wd
Enclosure(s)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION—_-- LOT5 5
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILLIITTY �` PROPERTY SIZE
SUBDIVISION \V ����> CZo�� ^�s � ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation Byt Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe% So -
HORIZON I DEPTH Gil
Texture groupC L Cl-
Consistence
Structure �� C
Mineralogy •,1
HORIZON II DEPTH
Texture group (Z C-
Consistence
Structure
Mineralogy \
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON — —
SAPROLITE —
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: •S EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC.-Concave slope. CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable I FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
-tSaprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)
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Davie County Health Department
and Come Heafth Agency
Environmenta(Health Section
' P.O.BOK 848/ 210 HOSPITAL STREET
COURIER#09-4-06
MOCKSwLLE,N.C.27028
PHONE:(704)634-8760
April 16, 1997
Eugene Bennett
107 Mail Ln.
Mocksville, NC 27028
Re: ' Site Evaluation
Northbrook II/Lot 32
Dear Mr. Bennett:
As requested, a representative from this office visited the
aforementioned site on April 15, 1997. Based upon the information
provided on the application for site evaluation and after the evaluation
was completed, the site was found to,'be provisionally suitable for the
installation of an on-site sewage disposal system.
>r
If you have any questions, please feel free to contact this office.
Sincerely,
Charles E. Little, R.S. • -
Environmental Health Section
CL/wd
Enclosure(s)
cc: Zoning Office
NOTE:
7hW property is subject to ON soeerrnnb, right-of-nays,
streets and attacwneeybt•i!any.as the same may appear of
•Site
rseard in the offke of the of OeedlL Chrk of Court,
Team or Cownty Tax Oftioe or wtdoh may haw been etoefuind by
g pn+srpUvo uoe and were not vWWe at the tirne of this
survey. This survey i,subject to any facts that may be Parkway Court
ditCia+ed by a f A and oocurate title scorch, NOT furnhhed
as of this dole. X Denotes Deed/Plat Corners
This mop or drowinrt�g and ony ocoornportyin9 f
documents an fue'ftiollad to this penon(s) named
Northbrook Drive
thereon and ro al6erotiorr or up by otfurs
is perndtted rxdas outhorized by Stone Lond Surveying Co.
Certlied of this survey mop wa not be issued
beyond rdn4ty(90)days of the original awey dote.
Center of Branch is Property Line
Atop not for recordation. homes Church Road Sp 1307
per
Precision 1:10,000+
'fro � \� `8 I R_— — S Vicinity Mop (Nat to Scots)
�3 --10
_ 1
!.George isobars Sbns,WWesalond Land�vvt+r,L-31ti1,oGrtly to,sfs
of the Weowing ce
' ❑ o. The Ob pbt kr of a Ganey that anstss a subQvbbn of land afMie
/ nn area of o aeangr or Rvadm0aft tint hes en o�ew<e ihd
repAsbe P-ode of knd;
/ ❑ b. That#6 plat b d a salver hart b ime~in such pe, Ole
aaaft or m'delps/gr vw*b unrs¢Aeed o,to an adfaake r t
/ the retdsir perab d Inrd:
/ y❑ a Thd"ie pbt b of a survq of en sin fwrcel ar pwaft
bed;
+ ❑ d. That Mb pha b d o earvey d aware caUgary,such s ttve
19 / woanilnatlon of eristlnt peeetti a'mat-ardwed server or a ter _
•peas+>e er dGfAdlfoe of..*%Aber:
/ ❑ s. Thd IM ineonna8ee audb6b to Mie ewveyar.Girh Mattern
�rrael.torrralr•s dd.rr,rer.8.e t.tfr►ed a<my prs,e.sbn,1I,:
p 2.290 Acres + / ebb•'°previsbers aarldrw In cols t4 se«.
18 /— per PB 7 ® PG 3
:
NORTHBROOK George R. Stone
Phase Two treed ,
rte Ssysyer,L-3 a2
r
P970PG3
1
Vf 1 declare that on 20
we surveyed the property shown on
M
this plat:
®
1
proposed
/ Off••'•
1 .Q •�� r
site
1--3162 Q, �
N�
0�G��.SLIKT.�'
5? BE
NORTHBROOK
N /FrA Phase Two f
+►� PS7OPG3
l ` #
Northbrook Drive
f"� NOM
BOUNDWY DEVELOPED FROM PARn& nEW SURVEY
AM DEED/PLAT OI A.
SOLID UMM I�PRII M SURVEYED i. AND
BROKEN LINES ANT COMPUTED LINES FROM
*ry r DEED/PLAT DATA.
ftJgt _ ftht•"Gf-� tF�ENO FC - race of Curb y i
r - bur Reber pip : t>tOCtC of QMta • 3�
4 r'
P _ f, LP - Power Gab Site Plain force:
Polo
-�
c*a —Oenoee.Yoocerfne►rt MN — w�wt testis Y
tAS hen PA" sat. CN - alone D460ace y
b
�d� pe COURSE � Larry McD ante l Builders = �.
-
4Cfl fktad goandsey ce - e;oboh sad" C-1 N 3i'46'08"W 53.27" chord. 56.18' arc, 50.00" radius Lot 19 '
-0- awolo d LtdlRfee -s- 8wer'tb" 'L-2 N O&W44"E 311.02'
NORTHBROOK `
-s-fine. •
uric— wrtMr oitNr L-3 S 7a` Qli"E 49:19' F'hass Two
Few-fr",o wv water vain L-4 N 33"2 '"2"E 32.87' Plat Book 7 O Page 3
— Wienfet�oetuenctticd ibirtt T8M TRsexlh AIwU L-5 S 77•QL!'18"E 47.85•
Mark a►� g 2.290 Aches- +/- per PS 7 0 PG 3
f2.'- Edo', tiP RRs wAf goaQrSpstc L-6 N 7M"AW E X41.12" 'SL3ALE SMP GOtlN11r sT/TE M1� 'j r
FY_- Edge of PwrMttcnt CN-GMie Tiiwlsioa P'edsr"1d
TP- TNephens P.de sal US-F mb%Tesntdattn.r Bar L-7 S 22e14MVE 18.03' r
w-saw tine oo—se�l,1. i ta.est out L-8 N 73e50',30"E 41,10'
1" = 5Q' Colottoln Davie Notch Caroline 6-16--3t>06
L-9 S 86'Od'37"E 11 Q.BN' r-
L-to s e5�1I•4r'E MOT Stone Land Surveying Company , e W.
a
� 0 �0 100 150
a L-11 S 57'51'11"W 532,34'
T-12 N 43'3!f'09"E 18.24' Mord. i$.OW arc, 25.00• radkx; Toe Line -
SG.UBrR5 11t+i.rt its. PLS L 3ttlZ 9706 ;
T-13 N 32'36'13"E 5 .23" chord, 36.18' fw% 50.OW radtm Tie Line WAPPED: 113 Drum Lone, Phone 336) 9"-4733 ,
i11My NL>V ;
GRAPHIC' SALE — FEET
GRS MockSARe. N.C_ 27028 9706
J
w
APPLICATION FOR SITE EVALUATIONAMPROVEMEN 2
' Davie County Health Department iS
Environmental Health Section APR _ 9
P.O. Box 848 1997
Mocksville,NC 27028
(704) 634-8760 1
� I
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed_-- Contact Person
Mailing Address (07-'(,/ '�'/ e" as z_ Home Phone
City/State/Zipf � �i.�f y ,(° .Z Td Z Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: �ite Evaluation [ ]Improvement Permit&ATC [ ]Both
4. System to Serve: [1]House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage Disposal
[ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other:Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply: [PI"County/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes kfNo
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***XA OF THE PROPERTY MUST BE
y SUBMITTED WITHAPPLICATION.
Property Dimensions: l ;� WRITE DIRECTIONS(fromi ocksville)TO PROPERTY:
Tax Office PIN: # - 4 0/
Property Address: Road Name '
City/zip
If in Subdivision provide information,as follows:
Name: 1917/9 i-V
Section: Lot#: 7�Z
This is to certify that the information provided is correct to the best of my knowledge. I understand that.any permit(s) issued hereafter are
subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by to conduct all testing procedures as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD(06-96)
THIS AREA MAY $E USED FOR bRAWINC7 YOUR SITE PLAN:
D e e- lv,4,P A W o l-X
�I
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